Assessing Infection Prevention Programs in Nursing Homes

On Friday, March 31, 2017, in a session at the Society for Healthcare Epidemiology of America (SHEA) Spring 2017 Conference, Nimalie Stone, MD, MS, Team Lead, LTC, Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention (CDC), discussed “infrastructure differences between infection prevention and control (IPC) programs in nursing homes and other post-acute care settings versus [IPC programs in] hospitals" in her session entitled, “Perspectives on Infection Prevention Programs in Post-acute and Long-term Care.”

Dr. Stone started off her session by examining some key infrastructure aspects that are needed to perform “good healthcare epidemiology and infection prevention” in hospital settings in particular, and across healthcare facilities in general. Some of these aspects include: dedicated full-time registered nurses (RNs) who are certified in IPC, a dedicated physician lead who also has experience in healthcare epidemiology, a dedicated IPC support committee, dedicated office space equipped with computers that have functional internet access, dedicated emails, integrated electronic healthcare records, and access to IT support.

To further explain the importance of these aspects, Dr. Stone highlighted a 2012 study which was conducted in British Columbia, Canada (BC), and analyzes gaps in IPC resources in long-term care facilities across the province. Researchers randomly polled 188 facilities out of the 800 total in the five health regions in BC. Among the polled facilities, 58% had no IPC physician support at all, whether in-house or external; 31% had facility local IPC committees, whereas 25% had no IPC committees at all; 36% had an on-site infection control practitioner (ICP), whereas 17% had no ICP available at all, neither in-house nor through a remote consult contract; and 41% of those infection control practitioners had more than 2 years of experience.

In a similar study published in 2016 which evaluated IPC infrastructure in nursing homes, researchers surveyed 990 facilities across the United States. The group found that 36% of nursing home respondents received an IPC citation in their Centers for Medicare and Medicaid Services (CMS) review, whereas 41% of non-respondents received citation. “This ended up being statistically significant,” said Dr. Stone. Most (84%) of the respondents from these facilities were RNs, and the average years of experience in IPC-related activities among these RNs was 11 years; 54% of these respondents had two or more other responsibilities in addition to IPC; 39% of respondents had some IPC-specific training, and 3% had the Certification in Infection Control credential, which is the standard certification in acute-care; 50% of facilities received financial resources for continuing education in infection prevention. “In terms of turn-over, 40% of these facilities reported that they had three or more people in this position in a 3-year time frame. That is at least a new person every year, at best, but probably you had people cycling even faster.”

Dr. Stone addressed the infection preventionists and epidemiologists in the audience, saying, “Just thinking about your own work in infection prevention and healthcare epidemiology, if you have that kind of turn-over in your infection prevention leadership, it [would be] very hard to get anything started, let alone sustained.”

When giving an example of an effective strategy to improve infrastructure in long-term care settings, Dr. Stone cited the CDC’s Infection Control Assessment Tools- Long Term Care Facilities. In 2015, “the CDC, [with the aid of] Ebola Response Supplemental Funding, was able to send some dedicated resources to state and local health departments, to work beyond hospitals and beyond Ebola assessment… to do more basic assessments and educational visits to providers interested in getting support for their infection prevention and control programs,” said Dr. Stone. She continued, “Where we see the most value from this investment has been outside of hospitals, where health departments have been able to get in front of nursing home providers, hemodialysis clinics, and outpatient clinics. These are the settings where we often don’t [put] as many resources toward.”

Long-term facilities are assessed along the following domains: policies and procedures, staff training and education, auditing and monitoring adherence to policies, feedback to staff adherence, and availability of supplies, and infrastructure to support activities.

To exemplify the assessment tools, Dr. Stone shared “hot off the press” CDC data on infrastructure assessment of IPC programs in long-term care facilities from January 2017. Forty-two health department partners across the country carried out 618 infection prevention assessments in nursing homes, 85% of which included on-site visits by Infection Control Assessment and Response (ICAR) teams. Almost all of the facilities in question (96%) had a dedicated person in charge of coordinating the IPC program, which was aligned with nursing home regulatory requirements. However, less than half (48%) of these designated individuals were trained in infection control. “This still seems pretty high to me, actually,” declared Dr. Stone.

She went on to say that most of the health departments had a clear-cut designation of what applied as proper infection control training, and even developed accessible content on infection prevention for nursing home providers. In addition, some health departments supplied funding to nursing home providers to send a staff person to an infection prevention course.

Commenting on the January 2017 assessment results, Dr. Stone said, “Those numbers look pretty high when you take them individually, but this really jumped out at me: when you look at all elements in place for that domain, only a third [35%] of the homes that were assessed had everything. I don’t think anything on that list was [a] super high-stretch goal.” Some of the areas where nursing homes were lacking included basic policies about emergency preparedness, training, and dedicated time for infection prevention practices.

The findings from these assessments showed that leadership investment and support for IPC programs is highly variable across the board; in addition, many of the staff who were in charge of the IPC programs in their respective nursing homes did not receive adequate training and did not have enough dedicated time to run the IPC programs. Furthermore, many of the policies that these facilities had in place were based off of generic templates and not customized to the specific facility or residents’ needs.

Visits to these facilities allowed health departments to establish new relationships with the nursing home staff, and provided for a “positive learning experience for both providers and healthcare departments.” Most importantly, these visits “allowed health departments to identify and develop long-term care-specific training and resource needs to strengthen IPC programs.”

Ultimately, major infrastructure gaps exist in IPC programs throughout US nursing homes. Some areas that need improvement include staff training, and designated time to focus on these programs. According to Dr. Stone, thankfully, “health department assessments of nursing home IPC programs informed the development of education and resources.”

“Now what we have to do is work together to help these facilities, close those gaps, and learn from them how we can better educate and provide resources to make [these facilities] successful in this effort. And, I think it’s incredibly encouraging to know that nursing homes in the states that have access to tailored infection prevention training and resources have the capacity to really have better outcomes, in terms of patient safety and resident safety,” Dr. Stone concluded.

DISCLOSURES

None

The content of the presentation reflects Dr. Nimalie Stone’s opinion and does not necessarily reflect the official position of the CDC.

SOURCE

SHEA Spring 2017 Conference

PRESENTATION

Through the Looking Glass: Perspectives on Infection Prevention Programs in Post-acute and Long-term Care